Cardiac complications secondary to iron overload are the leading cause of death in beta-thalassemia major. Approximately two thirds of patients maintained on the parenteral iron chelator deferoxamine ...have myocardial iron loading. The oral iron chelator deferiprone has been demonstrated to remove myocardial iron, and it has been proposed that in combination with deferoxamine it may have additional effect.
Myocardial iron loading was assessed with the use of myocardial T2* cardiovascular magnetic resonance in 167 patients with thalassemia major receiving standard maintenance chelation monotherapy with subcutaneous deferoxamine. Of these patients, 65 with mild to moderate myocardial iron loading (T2* 8 to 20 ms) entered the trial with continuation of subcutaneous deferoxamine and were randomized to receive additional oral placebo (deferoxamine group) or oral deferiprone 75 mg/kg per day (combined group). The primary end point was the change in myocardial T2* over 12 months. Secondary end points of endothelial function (flow-mediated dilatation of the brachial artery) and cardiac function were also measured with cardiovascular magnetic resonance. There were significant improvements in the combined treatment group compared with the deferoxamine group in myocardial T2* (ratio of change in geometric means 1.50 versus 1.24; P=0.02), absolute left ventricular ejection fraction (2.6% versus 0.6%; P=0.05), and absolute endothelial function (8.8% versus 3.3%; P=0.02). There was also a significantly greater improvement in serum ferritin in the combined group (-976 versus -233 microg/L; P<0.001).
In comparison to the standard chelation monotherapy of deferoxamine, combination treatment with additional deferiprone reduced myocardial iron and improved the ejection fraction and endothelial function in thalassemia major patients with mild to moderate cardiac iron loading.
Aims
Troponin measurement is used in the assessment and risk stratification of patients presenting acutely with chest pain when the main cause of elevation is coronary artery disease. However, some ...patients have no coronary obstruction on angiography, leading to diagnostic uncertainty. We evaluated the incremental diagnostic value of cardiovascular magnetic resonance (CMR) in these patients.
Methods and results
Sixty consecutive patients (mean age 44 years, 72% male) with a troponin-positive episode of chest pain and unobstructed coronary arteries were recruited within 3 months of initial presentation. All patients underwent CMR with cine imaging, T2-weighted imaging for detection of inflammation, and late gadolinium enhancement imaging for detection of infarction/fibrosis. An identifiable basis for troponin elevation was established in 65% of patients. The commonest underlying cause was myocarditis (50%), followed by myocardial infarction (11.6%) and cardiomyopathy (3.4%). In the 35% of patients where no clear diagnosis was identified by CMR, significant myocardial infarction/fibrosis was excluded.
Conclusion
CMR is a valuable adjunct to conventional investigations in a diagnostically challenging and important group of patients with troponin-positive chest pain and unobstructed coronary arteries.
2 There is excellent subendocardial resolution of the late gadolinium enhancement (LGE) CMR technique to detect scar tissue with a spatial resolution of 1 g of myocardium. 3 More recently, ...T2-weighted spin echo sequences such as STIR (short tau-inversion recovery) have been validated in identifying myocardial inflammation or oedema that may accompany scarring both in acute infarction and myocarditis. 4, 5 CMR does not involve the use of ionising radiation and is a very safe technique. In patients with ischaemic aetiologies, the amount of scar tissue correlates closely with the likelihood of inducible ventricular tachycardia on electrophysiological studies. 29 Quantification of the peri-infarct zone has a high predictive value for clinically significant arrhythmias and so may have a role in guiding adjunctive invasive therapies such as ICDs. 30 In DCM, the presence of mid-wall fibrosis is associated with an increased incidence of all cause mortality and unplanned hospitalisation.
Our aim was to report on a survey initiated by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) concerning opinion on the evidence relating to dual antiplatelet therapy ...(DAPT) duration after coronary stenting.
Results from three randomised clinical trials were scheduled to be presented at the American Heart Association Scientific Sessions 2014 (AHA 2014). A web-based survey was distributed to all individuals registered in the EuroIntervention mailing list (n=15,200) both before and after AHA 2014. A total of 1,134 physicians responded to the first (i.e., before AHA 2014) and 542 to the second (i.e., after AHA 2014) survey. The majority of respondents interpreted trial results consistent with a substantial equipoise regarding the benefits and risks of an extended versus a standard DAPT strategy. Two respondents out of ten believed extended DAPT should be implemented in selected patients. After AHA 2014, 46.1% of participants expressed uncertainty about the available evidence on DAPT duration, and 40.0% the need for clinical guidance.
This EAPCI survey highlights considerable uncertainty within the medical community with regard to the optimal duration of DAPT after coronary stenting in the light of recent reported trial results. Updated recommendations for practising physicians to guide treatment decisions in routine clinical practice should be provided by international societies.
Our aim was to report on a survey initiated by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) collecting the opinion of the cardiology community on the invasive ...management of acute coronary syndrome (ACS), before and after the MATRIX trial presentation at the American College of Cardiology (ACC) 2015 Scientific Sessions.
A web-based survey was distributed to all individuals registered on the EuroIntervention mailing list (n=15,200). A total of 572 and 763 physicians responded to the pre- and post-ACC survey, respectively. The radial approach emerged as the preferable access site for ACS patients undergoing invasive management with roughly every other responder interpreting the evidence for mortality benefit as definitive and calling for a guidelines upgrade to class I. The most frequently preferred anticoagulant in ACS patients remains unfractionated heparin (UFH), due to higher costs and greater perceived thrombotic risks associated with bivalirudin. However, more than a quarter of participants declared the use of bivalirudin would increase after MATRIX.
The MATRIX trial reinforced the evidence for a causal association between bleeding and mortality and triggered consensus on the superiority of the radial versus femoral approach. The belief that bivalirudin mitigates bleeding risk is common, but UFH still remains the preferred anticoagulant based on lower costs and thrombotic risks.
Scans can be oriented in any plane of the body and are not limited by acoustic windows. Because of its three dimensional nature, magnetic resonance imaging has become the ideal method for measuring ...ventricular mass and volume. 2 Some patients are not suitable for the procedure, such as those with cardiac pacemakers or defibrillators. Recent advances Cardiovascular magnetic resonance imaging is the newest technique for non-invasive cardiology It assesses cardiac function, mass, and volume and can detect myocardial infarction and fibrosis Computed tomography is used to quantify coronary calcium, high scores being related to increased risk, but its use remains controversial Myocardial perfusion scintigraphy single photon emission computed tomography is cost effective in investigating patients with suspected coronary disease Ambulatory blood pressure monitoring is now a valuable technique for guiding practice in hypertension The level of B natriuretic peptide increases with ventricular dysfunction, thus providing prognostic information Cardiovascular magnetic resonance imaging has a rapidly increasing role in cardiology (box 1) and is routinely used to assess anatomy, cardiovascular function, and blood flow.
The article discusses the growing role of cardiovascular magnetic resonance in both the diagnosis of myocardial infarction and its subsequent management, including the management of any resulting ...complications. The current roles of magnetic resonance coronary angiography and magnetic resonance perfusion are also reviewed.
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